The Surge--Why slowing measures are important right now

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Illustration from Business Insider

The idea is to slow the rate so that all of the people needing care do not arrive to the hospital at the same time. When too many arrive, they are not able to help them all, and deaths increase.

Around five percent of people who get Covid 19 require ventilation to assist with breathing.

From the WHO situation report for March 6:

For COVID-19, data to date suggest that 80% of infections are mild or asymptomatic, 15% are severe infection, requiring oxygen and 5% are critical infections, requiring ventilation. These fractions of severe and critical infection would be higher than what is observed for influenza infection

5 percent doesn't sound like a lot. However, when applied to large populations, it can become an issue if many are infected quickly. Here is what happened in Italy:

Coronavirus cases are pushing Italy's hospitals to the brink

Lombardy, the region around Milan that accounts for more than a fifth of Italy’s economic output, is by far the worst-affected part of the country. It had 5,469 cases, including 440 in intensive care, as of Monday afternoon.

Cases have since increased

Some doctors have said that they sometimes make the call on who gets treatment based on the age of the patient. In some areas, hospitals are suspending other treatments to focus personnel on the contagion.

A doctor who asked not to be named because of potential repercussions painted a dire picture of the situation in a hospital in Milan. While the coronavirus is best known for causing severe disease in elderly patients, even some young people are affected, the doctor said, and without sufficient beds and ventilators, some can’t be treated.

The hundreds of patients needing treatment for pneumonia have swamped the supply of available specialists, the Milan doctor said. Physicians such as gastroenterologists, who normally focus on the digestive system, have been conscripted to help out with lung patients, and they’re still not enough, the doctor said.

Coronavirus: 'We must choose who to treat,' says Italian doctor


Since there is, unfortunately, a disproportion between hospital resources, resuscitation beds and critically ill patients, not everyone can be intubated,” Salaroli said. “We decide based on age and state of health,” he added.

The Extraordinary Decisions Facing Italian Doctors

Today, Italy has 10,149 cases of the coronavirus. There are now simply too many patients for each one of them to receive adequate care. Doctors and nurses are unable to tend to everybody. They lack machines to ventilate all those gasping for air.

Now the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has published guidelines for the criteria that doctors and nurses should follow in these extraordinary circumstances.

Those who are too old to have a high likelihood of recovery, or who have too low a number of “life-years” left even if they should survive, will be left to die. This sounds cruel, but the alternative, the document argues, is no better. “In case of a total saturation of resources, maintaining the criterion of ‘first come, first served’ would amount to a decision to exclude late-arriving patients from access to intensive care.”

In addition to age, doctors and nurses are also advised to take a patient’s overall state of health into account: “The presence of comorbidities needs to be carefully evaluated.” This is in part because early studies of the virus seem to suggest that patients with serious preexisting health conditions are significantly more likely to die. But it is also because patients in a worse state of overall health could require a greater share of scarce resources to survive: “What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.”

This is also the concern in the USA:

Hospitals gird for coronavirus surge after years of cutbacks

With a potential surge of coronavirus patients, there may not be enough beds, equipment and staff to handle an epidemic. Executives face tough decisions about who could have to be isolated and, in some cases, need oxygen, ventilators and protective gear that’s already in short supply.

The hospitals have already worked through a bad flu season, which has some worried that there may not be enough beds should the coronavirus cases surge, as some models predict.

“This is not going to be a financial issue,” said New York Gov. Andrew Cuomo. “If anything … it will be a capacity issue, the number of beds.”

“Given that we’ve had a month or more of prep time, we have created contingency plans and will have additional beds available … but the actual ICU beds and ventilators are somewhat fixed and those numbers are what they are,” said Mark Mulligan, director of NYU Langone Health’s division of infectious diseases and immunology.

“Every hospital has limited, finite ability to surge,” said NYU Langone's Mulligan.

 

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https://www.washingtonpost.com/heal...us-numbers-we-really-should-be-worried-about/

The United States has roughly 2.8 hospital beds per 1,000 people. South Korea, which has seen success mitigating its large outbreak, has more than 12 hospital beds per 1,000 people. China, where hospitals in Hubei were quickly overrun, has 4.3 beds per 1,000 people. Italy, a developed country with a reasonably decent health system, has seen its hospitals overwhelmed and has 3.2 beds per 1,000 people.

 

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This Wikipedia article provides details of beds per thousand people for OECD countries.

 

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From King County Washington's alert yesterday:

COVID-19 is spreading in King County, with hundreds of cases reported to date. We expect the case count to double every 5-7 days. A key Public Health goal is to minimize the number of people who get seriously ill at the same time, so that those who are at risk for severe illness are able to get the care they need. If too many people get very sick all at once, this will put an unmanageable burden on our health care system. If that happens, people requiring care may not be able to get it when they need it. Every King County resident has a responsibility to each other to make sure our community collectively lessens the impact of this disease

 

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U.S. hospitals brace for 'tremendous strain' from new virus

U.S. hospitals are setting up circus-like triage tents, calling doctors out of retirement, guarding their supplies of face masks and making plans to cancel elective surgery as they brace for an expected onslaught of coronavirus patients.

Depending on how bad the crisis gets, the sick could find themselves waiting on stretchers in emergency room hallways for hospital beds to open up, or could be required to share rooms with others infected. Some doctors fear hospitals could become so overwhelmed that they could be forced to ration medical care.

The United States is still facing an active flu season, and many hospitals are already running at capacity caring for those patients. The new virus will only add to that burden, said Dr. Bruce Ribner an infectious-disease specialist at Emory University’s medical school.

In New York state, hit by the largest U.S. cluster of cases, the Health Department is accelerating regulations to get nursing students certified to work more quickly and is asking retired doctors and nurses to offer their services, Gov. Andrew Cuomo said.

“Studies predict that a moderate outbreak could result in 200,000 patients needing intensive care,” said Dr. Leana Wen, an emergency medicine specialist at George Washington University. “The U.S. only has 100,000 intensive care beds, and most are already occupied. If tens of thousands become sick at once, people will simply not receive the care that they need."

 

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10 states with the fewest community hospital beds per 1,000 population: Oregon may be the state most in need of staffed beds for community hospitals, according to data compiled by the Kaiser Family Foundation.

10 states with the fewest beds per 1k population:

1. Oregon: 1.6
2. Washington: 1.7
3. New Mexico: 1.8
4. Utah: 1.8
5. California: 1.8
6. Colorado: 1.9
7. Maryland: 1.9
8. Arizona: 1.9
9: Idaho: 1.9
10. Hawaii: 1.9

 

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Critical Care and the COVID-19 Outbreak in Italy: Early Experience and Forecast

In Lombardy, the precrisis total ICU capacity was approximately 720 beds (2.9% of total hospital beds at a total of 74 hospitals); these ICUs usually have 85% to 90% occupancy during the winter months.

There was an immediate sharp increase in ICU admissions from day 1 to day 14. The increase was steady and consistent. Publicly available data indicate that ICU admissions (n = 556) represented 16% of all patients (n = 3420) who tested positive for COVID-19. As of March 7, the current total number of patients with COVID-19 occupying an ICU bed (n = 359) represents 16% of currently hospitalized patients with COVID-19 (n = 2217). All patients who appeared to have severe illness were admitted for hypoxic respiratory failure to the COVID-19 dedicated ICUs.

During the first 3 days of the outbreak, starting from February 22, the ICU admissions were 11, 15, and 20 in the COVID-19 Lombardy ICU Network. ICU admissions have increased continuously and exponentially over the first 2 weeks. Based on data to March 7, when 556 COVID-19–positive ICU patients had been admitted to hospitals over the previous 15 days, linear and exponential models were created to estimate further ICU demand.

The proportion of ICU admissions represents 12% of the total positive cases, and 16% of all hospitalized patients. This rate is higher than what was reported from China, where only 5% of patients who tested positive for COVID-19 required ICU admission.

 

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Ventilator companies are trying to meet global demand.

‘We’ll take them all’: Demand for ventilators spikes as coronavirus looms

Officials at another manufacturer, Drägerwerk AG & Co., told ABC News they just received an order for 10,000 ventilators from the German government. “The delivery of the order will stretch across the entire year and requires a substantial increase of the production capacity,” a spokesperson said.

Bob Hamilton, the chief executive of the Reno-based Hamilton Medical Inc., told ABC News that his team is fielding calls from hospitals around the world and doing its best to meet the demand. Hospitals are saying “we’ll take them all,” Hamilton said.